Improving Understanding of Reflexivity in Family Medicine: Development of an Educational Tool Based on a Rapid Review

This article was migrated. The article was marked as recommended. Background: In the last decade, reflexivity has emerged as a key concept in family medicine, as evidenced by its increasing integration in competency statements and frameworks in the field. However, the concept of reflexivity is inconsistent and ill-defined in medical education literature, with variable purposes and associated processes, which is an important barrier to learning and implementing reflective practices. This project built on the results of a rapid review to develop an educational tool supporting the learning and teaching of reflexivity in family medicine. Methods: We conducted a rapid review of quantitative, qualitative and mixed studies relating to reflexivity in family medicine between May 2007 to May 2017 in PubMed, Embase, PsychInfo, CINHAL, ERIC and Education Source. Two reviewers independently identified, selected and reviewed studies. Results of the review were used to frame the content of the tool. Results: Our research strategy initially identified 810 studies, from which 65 studies were retained for analysis. The different conceptions of reflexivity encountered in the included studies were analyzed using thematic analysis. Four conceptions of reflexivity (i.e. clinical, professional, relational and social reflexivity), with related definitions, goals and processes were identified in the included studies and were used as a basis to develop the Reflexivi-Tool. Conclusion: There is a need to provide clear guidelines regarding the purpose and process of reflexivity, as well as better equipping mentors so they can better facilitate these kinds of skills. Based on a rapid review, this study has allowed the development of a tool that presents and clarifies four main types of reflexivity for medical practice in a concise and user-friendly way. Tools such as Reflexivi-Tool are crucial to support reflective processes that target different dimensions of professionalism.


Background
Reflexivity is a concept emerging from social sciences that has generated a lot of interest in a wide range of disciplines, such as education, sociology, organizational sciences, psychology, nursing and medicine (D'Cruz, Gillingham and Melendez, 2007;Mann, Gordon and MacLeod, 2009).Generally conceived as an alternative form of professional learning rooted in experience and reflection on experience, reflexivity appears to be a crucial component of responsible professional practice and its continuous improvement (Mezirow, 1990;Issitt, 2003;Gustafsson and Fagerberg, 2004;Mann, Gordon and MacLeod, 2009).
In medicine, reflexivity is conceived as a cross-cutting competence that enables health care providers to build new knowledge repertoires from their experiences, to deal with complex and unusual situations in their practice, and to adapt to changes in the health system by promoting continuous learning and adaptation (Mann, Gordon and MacLeod, 2009;Sandars, 2009;Wald and Reis, 2010;Menard and Ratnapalan, 2013).Reflexivity, reflection and reflective practice are concepts promoted in a wide variety of competency statements at all levels of medical education, both nationally and internationally.For instance, the Accreditation Council for Graduate Medical Education competencies (US), the CanMEDS-MF competency framework (Canada) and the European Federation of Internal Medicine evoke reflective practice in relationship with the development of clinicians' core competencies, such as professionalism (Tannenbaum, 2009;Frank, 2015).According to the CanMEDS-FM, reflexive clinicians demonstrate "awareness of self and an understanding of how one's attitudes, beliefs, assumptions, values, preferences, feelings, privilege and perspective impact their practice", and reflect "on practice events, especially critical incidents, to deepen self-knowledge and recognize when something needs to change and does it" (p.18).The ability to think critically and learn from experience is also described by Mann, Gordon and MacLeod (2009) as a key element that differentiates the novice from the expert in medical practice and the exercise of his clinical reasoning.
An important challenge to understanding reflexivity is that terminology and definitions of this concept are highly variable in literature, hindering the concept's full application in training and professional practice (Mann, Gordon and MacLeod, 2009;Chaffey, de Leeuw and Finnigan, 2012).For instance, our review of reflexivity in medical education (described in this article) found "reflection", "self-directed learning", "habits of mind", "reflective practice", "reflective learning", "mentalization" and "insightful practice" as variable terms related to reflexivity with more or less consistency (Bethune and Brown, 2007;Laidlaw et al., 2007;Davidsen and Reventlow, 2011;George et al., 2013;Al-Imari, Yang and Pimlott, 2016).A commonly cited definition of reflexivity is that of Sandars, which sees reflection (i.e.reflexivity) as "a metacognitive process that occurs before, during and after situations with the purpose of developing greater understanding of both the self and the situation so that future encounters with the situation are informed from previous encounters" (Sandars, 2009, p. 685).As for Chaffey, de Leeuw and Finnigan (2012), they view reflection in medicine as "the action of thinking critically and consciously about one's practice, so as to reduce the risk of non-conscious habitual practice, which can lead to compromised patient care and safety " (p. 198).If processing of experience to inform future action appears as a recurrent feature of many definitions of reflexivity, the purposes and goals of this type of activity vary greatly: reflexivity is sometimes considered as an approach to develop a therapeutic relationship or professional expertise (Sandars, 2009), a strategy to improve judgement, to personally develop, or to contextualize practice (Chaffey, de Leeuw and Finnigan, 2012), and as a means to identify learning needs, develop the professional identity or build integrated knowledge bases (Mann, Gordon and MacLeod, 2009).
Lack of coherence in the definition, purposes and goals of reflexivity hinders understanding of medical students and clinicians who have never been introduced to the concept and have a limited practical experience (Aukes et al., 2007;Aukes et al., 2009;Leung et al., 2010;Chaffey, de Leeuw and Finnigan, 2012;Sandars, Kokotailo and Singh, 2012).This can be an obstacle for medical professors who must try to synthesize information by integrating the multitude of definitions available.In addition, despite the emphasis placed on reflexivity in medical training and continuing medical education, there is a surprising lack of resources to support professors in fostering reflective ability in trainees and learners (Mann, Gordon and MacLeod, 2009).Some studies have found that clarity in the purpose of the reflective process and reflexive role models are key to facilitate the integration of this skill in trainees and students (Leung et al., 2010;Chaffey, de Leeuw and Finnigan, 2012).Therefore, synthesizing and simplifying the concept of reflexivity for students and clinical teachers is essential to facilitate the implementation of reflexivity in clinical practice.

Context of the project
Since 2009, reflexive activities in groups have been implemented in the teaching curriculum of the Family Medicine Residency Program at Université Laval.The purposes of these activities are to consolidate the process of reflection on action and to develop reflexive skills in residents of the program.In 2016, the evaluation of the program uncovered some dissatisfactions and questions related to reflexive activities, their relevance and their ability to stimulate a real reflexive process among participants.For instance, the evaluation results revealed a limited understanding of reflexivity and mixed appreciation of the activities in their current format, which were mistakenly designed by participants as pretexts for ventilation episodes, simple/trivial discussions, or masterful teaching.These results highlight vagueness and confusion surrounding the notion of reflexivity and its application in the context of the Family Medicine Residency Program at Université Laval.Following this evaluation, a need to adequately equip clinician teachers and family medicine supervisors to improve their understanding of reflexivity, its practical application in their practice, and ways in which it can be developed among residents was identified.
We conducted this rapid review in the context of a larger project at Université Laval, which aimed to co-develop a relevant tool to support clinical teachers affiliated with the Family Medicine Residency Program in their role of reflexive mentors.The goal of this review is to synthesize recent scientific literature on reflexivity in family medicine and to provide a portray of different conceptions of reflexivity that exist within the field.Results of the review has allowed to frame the contents of the educational tool.

Methods
We used a rapid review (Khangura et al., 2012) to quickly synthetize relevant literature on reflexivity in family medicine, which informed the tool development within the context of our larger study.The literature search protocol was developed in consultation with a librarian research specialist and is described using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (Moher et al., 2009).

Data sources
We searched six online databases: PubMed, Embase, PsychInfo, CINHAL, ERIC and Education Source.Based on a systematic approach, we searched each database using a predefined list of keywords related to reflexivity (see Supplementary File 1 for the full search strategy), which was validated by the librarian research specialist.The last search was conducted on the May 25 th , 2017.We imported and collated the results of the database searches using Endnote software version X9.

Studies selection
The entire initial selection of studies based on the titles and abstracts of the corpus was conducted by two reviewers (NTD and LG).Any discrepancies were resolved by consultation with a third reviewer (MCT).To be included in the review, each study had to adhere to the following criteria: 1. be a primary qualitative, quantitative, or mixed methods study published in the last 10 years (May 2007 to May 2017); 2. written in either English or French; 3. conducted in one or many Western countries; 4. describing an intervention aiming to develop reflexivity or studying how family general practitioners or residents implement reflexivity in their current practice.
Studies reporting interprofessional interventions or including numerous specialists were included as long as they also involved family medicine practitioners or students.

Data extraction and analysis
Data was extracted by a first reviewer (NTD) and validated by another (LG), with verification done by the corresponding author (MCT).Data synthesized from the studies included was imported into a spreadsheet with the following column headings: authors, year of publication, study title, definition of reflexivity or associated concepts (where appropriate), usefulness of reflexivity for practice or goals (if mentioned) (See Supplementary File 2).Two team members conducted a thematic analysis (LG, MCT), focusing on the definition of reflexivity and the characteristics of the reflection process involved.The first author (MCT) generated the initial codes and themes related to the different forms of reflexivity, their usefulness/goals and their process.A second coder (LG) validated this analysis.Coding differences were resolved by consensus.

Rapid review results
Our research strategy initially identified 810 studies.After the removal of duplicates (n= 269), the corpus was reduced to 541 studies.The remaining corpus was evaluated based on titles and abstracts and allowed the exclusion of 303 studies.Therefore, the complete texts of 238 studies were accessed, and 65 studies were retained for analysis (see Figure 1).
The different conceptions of reflexivity encountered in the 65 studies (see Supplementary File 3) were analyzed using thematic analysis and regrouped in four main types of reflexivity, with different goals, processes and uses for family medicine practice (see Table 1).The first conception of reflexivity, which we named "clinical reflexivity", was identified in 33 studies.Clinical reflexivity is identified as a form of reflection initiated by the detection of a clinical error, the identification of a gap in information or professional skills.This type of reflexivity often emerges from a situation where the clinician notices a discrepancy between the desired effects and the actual effects of his actions.The goal of clinical reflexivity is to improve technical and clinical skills by taking the necessary steps to meet educational and professional needs."Professional reflexivity" is another conception of reflexivity encountered in 40 studies that is closely associated with Schön's concept of reflection-on-action (Schön, 1984).This kind of reflexivity occurs when a new, ambiguous, or complex situation arises.Being reflexive in these contexts is crucial because it helps to develop professional expertise by creating new patterns of action that will enable the complexity of the practice to be faced.This also creates new schemes of action to draw on that can be integrated with existing repertoires of potential action strategies.A third conception of reflexivity identified in 26 studies is related to introspection and being more aware of feelings, emotions and values in relation to certain situations in professional practice."Relational reflexivity" is often initiated by the awareness of an emotional state related to a situation experienced.The goal of this type of reflexivity is the development of an empathetic, healthy, and effective therapeutic relationship and process by allowing the healthcare provider to act with compassion and lucidity toward his patients.Finally, "social reflexivity" is a fourth conception of reflexivity reported by 22 studies as a form of reflection on practice sensitive to social considerations, in line with a critical epistemology of practice.This type of reflexivity is initiated by the clinician's need to make sense of his practice in relation to a broader sociopolitical context by emphasizing the social, ethical, and political aspects of his practice.By so doing, the clinician develops the noncognitive dimensions of professionalism, such as moral commitment, sense of mission and responsible practice.The four conceptions of reflexivity identified in the analysis helped to develop the formal content of the tool.

Development of the tool
The initial version of Reflexivi-Tool (in French Réflexi-Vite, literally "Reflect-fast") was developed in collaboration with the Family Medicine Residency Program managers based on local needs identified as well as the conceptual categories drawn from the literature review.The initial version of the tool was refined following a pre-test workshop with typical  users (i.e.clinical teachers of the program).Feedback offered by participants of the workshop was used to clarify descriptions in the tool and revise the name of some categories.The tool was designed to support reflexivity in different contexts: clinical, educational or supervisory activities; daily or punctual activities; facilitation as part of an individual or group approach; by users from the same profession (e.g.family medicine) or as part of interprofessional collaboration activities.
The final version of Reflexivi-Tool (see Supplementary File 4) presents four types of reflexivity as previously described (i.e.clinical, professional, relational and social) in a concise and user-friendly way.For each type, the trigger and focus of the reflection process, a role model name (e.g., the empathetic professional referring to relational reflexivity) and a definition is provided (What is it?).There is also a description of the usefulness of each type of reflexivity for practice (Why is it important?) in terms of the skills that it enables.It finally provides a description of the reflection process (How does it manifest?)and a list of question prompts (Questions to consider) that can be used in a supervisory context to support the reflection.Reflexivi-Tool allows for quick understanding of the type of reflexivity generated by a situation.
The tool is available in PDF and interactive PDF (optimized for smartphones) formats.
The tool was disseminated to the program's clinical teachers and residents through a series of four emails from January to May 2019, by an announcement on the online program portal and through a formal presentation to the program's teaching assistants in September 2018.A series of four short educational videos have also been produced to facilitate the understanding and adoption of the tool.Each video illustrates one of the four types of reflexivity through a staging between a resident and his/her supervisor.These videos have been shared in the emails and on the online program portal.

Conclusion
Reflexivity is an essential competency of clinicians allowing continued improvement and adaptation of practice in a constantly evolving healthcare system (Mann, Gordon and MacLeod, 2009;Sandars, 2009;Wald and Reis, 2010;Menard and Ratnapalan, 2013).However, in medical education literature, the concept of reflexivity is inconsistent and illdefined, with variable purposes and associated processes, which is an important barrier to learning and implementing reflective practices (Aukes et al., 2007;Aukes et al., 2009;Leung et al., 2010;Chaffey, de Leeuw and Finnigan, 2012).Several authors have highlighted the need to provide clear guidelines regarding the purpose and process of reflexivity, as well as better equipping mentors so they can better facilitate these kinds of skills (Carr and Carmody, 2006;Chaffey, de Leeuws and Finnigan, 2012).Based on a systematic approach to educational design, this study has allowed the development of a tool that presents and clarifies four main types of reflexivity for medical practice in a concise and user-friendly way.Educational devices and facilitation tools such as Reflexivi-Tool are crucial to support reflective processes that target different dimensions of professionalism, allowing not only improved clinical judgement and continued learning, but also a sense of responsibility and moral commitment in practitioners.
Take Home Messages • In the last decade, reflexivity has emerged as a key concept in family medicine.However, this concept of reflexivity is inconsistent and ill-defined in medical education literature, with variable purposes and associated processes.
• We conducted a rapid review to synthesize recent scientific literature on reflexivity in family medicine, which served as a basis to the development of an educational tool to support the learning and teaching of reflexivity.
• The results identify four main types of reflexivity (i.e.clinical, professional, relational, and social reflexivity) with related definitions, goals, processes.

Figure 1 .
Figure 1.Flow chart for the selection of eligible studies
Ndeye Thiab Diouf (MSc) is a PhD student in community health at Université Laval(Québec, Canada).Her doctoral thesis focuses on reflective practice as a strategy to improve health care professionals' training on shared decision making in order to foster share decision making implementation and collaborative practice in health care.document with their article.Figure 1.Source: Authors, based on the updated Prisma guideline for reporting systematic reviews (Page et al., 2021).Bethune, C. and Brown, J. B. (2007) Residents' use of case-based reflection exercises.Canadian Family Physician, 53(3), pp.471-476.Carr, S. and Carmody, D. (2006) Experiential learning in women's health: medical student reflections.Medical Education, 40(8), pp.768-774.Reference Source Chaffey, L. J., de Leeuw, E. J. and Finnigan, G. A. (2012) Facilitating students' reflective practice in a medical course: literature review.